Request Assistance from LAFF
Your Name *
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Contact Phone Number *
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E-mail *
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Street Address *
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City *
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State *
Your answer
Name of Pet *
Your answer
Pet Type *
Breed *
Your answer
Age *
Your answer
Gender *
Spayed/Neutered *
Primary Veternarian *
Your answer
Veterinary Clinic Name *
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Vet Clinic Telephone Number *
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Vet Clinic Address *
Your answer
Pet's Medical History (Please be specific) *
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Medications (prescribed & over the counter, include dosage and frequency) *
Your answer
Contact Information for any Specialty Veterinarian or Clinic involved in pet's care *
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Reason for Contacting LAFF *
Your answer
Estimated Cost of Treatment *
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Are you willing to see a different vet if necessary? *
Have you raised funds for your pet's treatment? *
Amount Raised *
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Funding Source (GoFundMe, etc.) *
Your answer
Do you have a Care Credit account? *
If so, how much credit is available? *
Your answer
Will you be able to document your need for financial assistance? Please provide a brief description of your current financial situation. *
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Where did you hear about us?
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Please add any additional helpful information below
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